title: Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials.
abstract: OBJECTIVE
  To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia.
  
  
  BACKGROUND
  It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality.
  
  
  METHODS
  We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥ 24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint.
  
  
  RESULTS
  A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39-0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients.
  
  
  CONCLUSIONS
  In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk-benefit analyses and professional care are recommended.
authors.affiliation: *Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Germany †Faculty of Medicine, Institute of Social and Preventive Medicine, University of Geneva, Switzerland ‡Department of Anesthesia and Intensive Care, Tenon University Hospital, Assistance Publique Hôpitaux de Paris, France §Anesthesiology Unit, School of Medicine and Pharmacology, University of Western Australia, Australia ¶Department of Anesthesia and Critical Care, University Hospital of Würzburg, Germany ‖Division of Anesthesiology, Geneva University Hospitals, and Faculty of Medicine, University of Geneva, Switzerland.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Pöpping
authors.forename: Nadia
authors.initials: N
authors.lastname: Elia
authors.forename: Hugo K
authors.initials: HK
authors.lastname: Van Aken
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Marret
authors.forename: Stephan A
authors.initials: SA
authors.lastname: Schug
authors.forename: Peter
authors.initials: P
authors.lastname: Kranke
authors.forename: Manuel
authors.initials: M
authors.lastname: Wenk
authors.forename: Martin R
authors.initials: MR
authors.lastname: Tramèr
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000379:methods*; D014943:Global Health; D006801:Humans; D009017:Morbidity / Q000639:trends; D011183:Postoperative Complications / Q000453:epidemiology* / Q000517:prevention & control*; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D013514:Surgical Procedures, Operative; D015996:Survival Rate / Q000639:trends